Challenges of calculating cost-effectiveness thresholds
Authors: Angel Paternina-Caicedo, Fernando De la Hoz-Restrepo, Nelson Alvis-Guzmán
Journal: The Lancet Global Health (2023)

The Article by Andres Pichon-Riviere and colleagues1Pichon-Riviere A Drummond M Palacios A Garcia-Marti S Augustovski F Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures.Lancet Glob Health. 2023; 11: e833-e842Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar is a welcome methodological addition to the field of health economics. The assumptions of the equations to derive the cost-effectiveness thresholds (CETs) reported in the research help gain insight into the macroeconomic structure of health-care expenditures in each country, reducing the methodological uncertainty of cost-effectiveness evaluations worldwide. This analysis follows a similar path used in previous research,2Paternina-Caicedo A. Estimating cost-effectiveness thresholds for 174 countries: a preliminary empirical study to inform health decision-making. 41st Annual Meeting of the Society for Medical Decision Making; Oct 20–23, 2019 (abstr 3I-4).Google Scholar in which health expenditures are used as a macroeconomic proxy of the costs of interventions in each jurisdiction. One potential limitation of the reported CET is the calculation of the per-capita health expenditures. According to equation 3 of their appendix (p 2), the expenditures are divided by life years of the entire cohort, whereas the expenditures used in the paper are divided by the population of the country. This change might underestimate the true CET reported in the analysis. Another limitation of this analysis is that there is no acknowledgment of the CET of new interventions for neglected, rare, or orphan diseases, for which this threshold would be higher due to the high number of resources needed to develop interventions. Furthermore, the differences in life expectancies and health expenditures are the average incremental cost-effectiveness ratio of new interventions. Assuming the incremental cost-effectiveness ratio of novel interventions follows a normal distribution, half of all novel interventions would be higher than these values, underestimating the true CET for novel interventions. These thresholds assume increasing health-care expenses and life expectancies. Although this assumption is correct in most situations, the potential changes in health-care expenses and life expectancies would have to be adjusted for macroeconomic shocks, such as war, pandemics (eg, COVID-19), or novel laws, among other countrywide events. The thresholds also assume an equal distribution of health services. According to the Global Burden of Disease study,3Lozano R Fullman N Mumford JE et al.Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1250-1284Summary Full Text Full Text PDF PubMed Scopus (260) Google Scholar effective health care coverage ranges from 27% to 89% in countries worldwide. Further expanded cost-effectiveness studies will be needed to address this gap, and the threshold for different subpopulations within a country is an open issue in health economics. Despite the limitations of the CETs of Pichon-Riviere and colleagues,1Pichon-Riviere A Drummond M Palacios A Garcia-Marti S Augustovski F Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures.Lancet Glob Health. 2023; 11: e833-e842Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar their usefulness is warranted. These thresholds are the lower limit of the true CET for every country. The mathematical derivation of the thresholds will be valuable for jurisdictions wanting to estimate the cost-effectiveness of novel interventions, and the values will be useful to elucidate the relationship between economic use of resources and health benefits in the rapidly growing scientific field of health economics. We declare no competing interests. Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expendituresThis approach, based on widely available data, can provide a useful reference for countries using economic evaluations to inform resource-allocation decisions and can enrich international efforts to estimate cost-effectiveness thresholds. Our results show lower thresholds than those currently in use in many countries. Full-Text PDF Open AccessChallenges of calculating cost-effectiveness thresholdsHealth systems around the globe use cost-effectiveness analysis to support health funding decisions. Cost-effectiveness analysis compares benefits associated with new technologies with benefits necessarily forsaken when resources are displaced to pay for the new technologies. Systems aiming to improve the health of their populations but facing a budget constraint should use cost-effectiveness thresholds (CETs) that reflect the health opportunity costs of funding decisions.1 Full-Text PDF Open AccessChallenges of calculating cost-effectiveness thresholds – Authors' replyWe welcome the interest of Laura Vallejo-Torres and colleagues and Angel Paternina-Caicedo and colleagues in our recent study.1 Full-Text PDF Open Access